{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T07:02:00Z","timestamp":1790060520201,"version":"4.0.1"},"reference-count":21,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T00:00:00Z","timestamp":1789948800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T00:00:00Z","timestamp":1789948800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["shmpublications.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Hospital Medicine"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Emergency department (ED) boarding at academic health centers delays care and limits access to specialized services. We evaluated a systemwide level\u2010loading program that transferred clinically appropriate admitted ED patients from an academic health center to affiliate or partner community hospitals with available capacity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a 28\u2010month pre\u2010post electronic medical record\u2010based evaluation from September 2023 through December 2025 in a multi\u2010hospital health system. The intervention included universal transfer center registered nurse screening of ED admissions, standardized patient communication, EMR\u2010integrated transfer tracking, hospitalist assumption of care for transfer\u2010pending patients, dedicated ambulance coverage, and a transfer receiving unit. Outcomes included transfer volume, ED boarding time, inbound transfers to the academic center, inpatient length of stay, early deterioration, mortality, readmissions, and transfer\u2010related adverse events.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      During the intervention, 537 patients were transferred. Transfer volume increased from 1.5 to 15.0 patients per week (rate ratio 10.3;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.01). Among transferred patients, ED boarding time declined from 6.5\u2009h in the first PDSA cycle to 2.9\u2009h by the final cycle. In adjusted analyses, transfer status was associated with 14.8 fewer ED boarding hours (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.01), a 16.4\u2010percentage\u2010point lower probability of rapid response activation or ICU upgrade within 48\u2009h (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.01), and no increase in mortality or length of stay. No transfer\u2010related adverse events were identified. Inbound transfers to the academic center increased 8% to 16%.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>A multidisciplinary level\u2010loading program substantially increased interhospital transfers, shortened ED boarding for transferred patients, and expanded complex\u2010care access without observed transfer\u2010related adverse events.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/jhm.70492","type":"journal-article","created":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T06:07:12Z","timestamp":1790057232000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Level\u2010loading across a health system: A collaborative model for interhospital transfers"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-6453-9739","authenticated-orcid":false,"given":"Obert","family":"Xu","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine Oregon Health and Science University, Oregon Portland Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Graven","sequence":"additional","affiliation":[{"name":"School of Public Health Oregon Health and Science University, Oregon Portland Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5550-1302","authenticated-orcid":false,"given":"Beech","family":"Burns","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine Oregon Health and Science University, Oregon Portland Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9210-5281","authenticated-orcid":false,"given":"Angela","family":"Alday","sequence":"additional","affiliation":[{"name":"Department of Medicine Oregon Health and Science University, Oregon Portland Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthias","family":"Merkel","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Perioperative Medicine Oregon Health and Science University, Oregon Portland Oregon USA"},{"name":"Mission Control Oregon Health and Science University, Oregon Portland Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James","family":"Clements","sequence":"additional","affiliation":[{"name":"Department of Medicine Oregon Health and Science University, Oregon Portland Oregon USA"},{"name":"Mission Control Oregon Health and Science University, Oregon Portland Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,21]]},"reference":[{"key":"e_1_2_11_2_1","unstructured":"Agency for Healthcare Research and Quality. Improving patient flow and reducing emergency department crowding: a guide for hospitals. Published September 2012. Accessed February 8 2025.https:\/\/ahrq-stage.ahrq.gov\/research\/findings\/final-reports\/ptflow\/section.1.html#:~:text=Nearly%20half%20of%20EDs%20report away%20from%20the%20closest%20hospit"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0203316"},{"issue":"5","key":"e_1_2_11_4_1","article-title":"Emergency department crowding: the canary in the health care system","volume":"2","author":"Kelen GD","year":"2021","journal-title":"NEJM Catal Innov Care Deliv"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.annemergmed.2009.02.001"},{"key":"e_1_2_11_6_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1553-2712.2011.01236.x"},{"key":"e_1_2_11_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jemermed.2012.05.007"},{"key":"e_1_2_11_8_1","volume-title":"Level\u2010Loading Patients Across a Healthcare System","author":"Lee AH","year":"2023"},{"key":"e_1_2_11_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2025.08.060"},{"key":"e_1_2_11_10_1","doi-asserted-by":"publisher","DOI":"10.1002\/jhm.70174"},{"key":"e_1_2_11_11_1","first-page":"2","article-title":"Right\u2010sizing care: transferring lower\u2010acuity patients from an academic medical center to a community hospital","volume":"2","author":"Kazberouk A","year":"2021","journal-title":"NEJM Catal"},{"key":"e_1_2_11_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2022.07.037"},{"key":"e_1_2_11_13_1","doi-asserted-by":"publisher","DOI":"10.3346\/jkms.2016.31.5.806"},{"issue":"5","key":"e_1_2_11_14_1","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1097\/01.JMQ.0000743384.54212.e7","article-title":"COVID\u201019 level\u2010loading: transferring emergency department patients to a partner academic medical center within a healthcare system","volume":"36","author":"Lee AH","year":"2021","journal-title":"Am J Med Qual"},{"key":"e_1_2_11_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2022.12.028"},{"key":"e_1_2_11_16_1","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1016\/j.ajem.2026.01.015","article-title":"Large academic enterprise load balancing: ED patient transfers to regional hospitals","volume":"102","author":"Shah M","year":"2026","journal-title":"Am J Emerg Med"},{"key":"e_1_2_11_17_1","unstructured":"Kaiser Family Foundation. State health facts: hospital beds per 1 000 population by ownership type.2022. Accessed March 8 2025.https:\/\/www.kff.org\/other\/state-indicator\/beds-by-ownership\/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22 %22sort%22:%22asc%22%7D"},{"key":"e_1_2_11_18_1","doi-asserted-by":"publisher","DOI":"10.1197\/j.aem.2003.07.017"},{"key":"e_1_2_11_19_1","volume-title":"Individual Hospital Statistics for Oregon: Statistics for Non\u2010Federal, Short\u2010Term, Acute Care Hospitals","author":"American Hospital Directory","year":"2026"},{"key":"e_1_2_11_20_1","unstructured":"HottmanS. OHSU opens centralized command center for statewide coordination of patient care.OHSU News. September 18 2024. Accessed January 24 2026.https:\/\/news.ohsu.edu\/2024\/09\/18\/ohsu-opens-centralized-command-center-for-statewide-coordination-of-patient-care"},{"key":"e_1_2_11_21_1","doi-asserted-by":"publisher","DOI":"10.1097\/JHQ.0000000000000293"},{"issue":"11","key":"e_1_2_11_22_1","article-title":"Intake hospitalist: a new role to maximize the safety and efficiency of interhospital transfers","volume":"4","author":"Hendricks MJ","year":"2023","journal-title":"NEJM Catal Innov Care Deliv"}],"container-title":["Journal of Hospital Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/shmpublications.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jhm.70492","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/shmpublications.onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/jhm.70492","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/shmpublications.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jhm.70492","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T06:07:16Z","timestamp":1790057236000},"score":1,"resource":{"primary":{"URL":"https:\/\/shmpublications.onlinelibrary.wiley.com\/doi\/10.1002\/jhm.70492"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,21]]},"references-count":21,"alternative-id":["10.1002\/jhm.70492"],"URL":"https:\/\/doi.org\/10.1002\/jhm.70492","archive":["Portico"],"relation":{},"ISSN":["1553-5592","1553-5606"],"issn-type":[{"value":"1553-5592","type":"print"},{"value":"1553-5606","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,21]]},"assertion":[{"value":"2026-05-08","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-24","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-09-21","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"jhm.70492"}}